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Abstract

Health effects of structural racism occur on cultural and institutional levels and potentiate racism on an interpersonal level. Consequently, efforts to mitigate the health effects of racism may require intervention on all levels. The effectiveness of these approaches may depend partly on the degree to which they address the underlying patterns of social cognition, shaping social norms and influencing thoughts, feelings, and expectations about oneself, one's relationships with others, and interactions with the healthcare system. This paper aims to evaluate the current approaches to addressing structural racism (via racism and health statements and training programs in diversity, equity, and inclusion or cultural competence). These interventions work to shift social cognition, and consequently, shape social behavior in the healthcare context. Our goal is to identify ways to maximize the potential of these approaches to address social cognition to guide efforts to achieve a more inclusive and equitable healthcare system.

Keywords

anti-racism social cognition diversity equity and inclusion healthcare racism and health statements

New paper alert! Join the movement to combat structural racism in health! Health care organizations are taking a stand with anti-racism statements and training. Our review suggests ways to enhance the effectiveness of these statements and strengthen culturally responsive healthcare training programs. We can maximize the benefits of anti-racism statements & training by focusing on their capacity to engage social cognition (i.e., thoughts, feelings, and attitudes about relationships with others) and to support social relationships.

Key Points

Momentum to reduce structural racism in health is growing.

Many healthcare organizations released antiracism statements to reinforce their commitment to justice.

New research suggests methods for improving training programs to guide culturally responsive healthcare.

We can maximize the benefits of anti-racism statements & training by focusing on their capacity to engage social cognition (i.e., thoughts, feelings, and attitudes about relationships with others) and to support social relationships.

Reducing racial disparities in health and promoting health equity is part of the national public health agenda (Office of Disease Prevention and Health Promotion, 2023). The role of structural racism in driving these health disparities was increasingly acknowledged during the COVID-19 pandemic, as racial disparities in COVID-related risk factors and racial disparities in COVID-19 incidence and mortality became evident (e.g., Do & Frank, 2021; Franz et al., 2022). The urgency of the need to dismantle structural racism grew in response to the wrongful deaths by police force of unarmed Black men and women (Egede & Walker, 2020; Eichstaedt et al., 2021).

Structural racism is pervasive, occurring on cultural and institutional levels and potentiating racism on an interpersonal level (Brondolo et al., 2023; Jones, 2000; Krieger, 2020). At all levels, racism affects social cognition, influencing mental representations of oneself and others. In turn, these mental representations shape expectations about social interactions and may influence the quality of social relationships beneficial for good health and effective healthcare delivery (Banaji et al., 2021; Brondolo et al., 2017). Consequently, efforts to prevent and mitigate the health effects of racism may require interventions operating on multiple levels—targeting institutional policies and individual actions, as well as individuals’ perceptions of the social world.

Cultural, institutional, and interpersonal approaches to address the effects of racism on health are underway in the healthcare sector. Since 2020, cultural communications concerning structural racism have changed. Many health-related organizations have publicly issued statements recognizing racism as a public health threat and declaring their intentions to promote health equity (Mendez et al., 2021; Paine et al., 2021). Organizations have publicly committed to institutional policies and procedures intended to eliminate bias and foster inclusivity and diversity in their organizations. To address discrimination in an interpersonal context, the Accreditation Council for Graduate Medical Education (ACGME) program requires physicians to develop skills in effective communication with diverse patient groups (ACGME, 2022; Atkinson et al., 2022). Training programs in diversity, equity, and inclusion (DEI) practices and culturally responsive care have been formally incorporated into some, although not all, graduate medical education programs and healthcare practices (Atkinson et al., 2022).

Each of these approaches may reduce racism and mitigate its health effects, in part, through psychosocial processes, including those that affect social cognition. Racism and health statements may strengthen individual egalitarian values and generate new social norms around inclusive and equitable treatment. Training, particularly when it is accompanied by institutional policies and procedures that support equity and inclusion, may modify negative social cognition about different cultural/racial groups and provide skills in social communication across groups. Current efforts are critical to support more effective and inclusive healthcare, but they need further development and testing. Research suggests that not only is there evidence of benefit from these interventions, but there are also indications of unintended negative consequences, including backlash (Cox & Devine, 2022; Kaiser et al., 2022).

This article aims to evaluate the capacity of cultural, institutional, and interpersonal approaches to shift social cognition and address racism in the healthcare context. Examining the effects of these approaches on social cognition may provide insights which can strengthen efforts to support culturally responsive health care and prevent unintended negative effects. We hope this focus on social cognition will help maximize the benefits of growing national efforts to reduce the effects of structural racism on health and achieve a more inclusive and equitable healthcare system.

Racism and Social Cognition

Social cognitive approaches are critical for efforts to address structural racism (Banaji et al., 2021; Brondolo et al., 2023). Social cognition refers to the mental structures and processes involved in perceiving and responding to the social world (Fiske, 1993; Fiske & Taylor, 1991). Social cognitive processes at different levels are involved both in the development of prejudice and the psychosocial effects of exposure to discrimination. Dimensions of social cognition, including social categorization, classify individuals into in-groups and out-groups. Stereotyping processes link expected characteristics to all group members. Stereotyping justifies prejudices, and prejudices drive stereotyping (Neuberg et al., 2020; Phills et al., 2020).

To illustrate, implicit bias is one frequently assessed dimension of social cognition linked to racial discrimination at all levels (Banaji et al., 2021). Implicit bias refers to negative attitudes about the members of an out-group, attitudes that may be held outside of conscious awareness (Forscher et al., 2019). Implicit bias can provide some insights into an individual's mental representations of people from different social status positions (Cunningham et al., 2004; Devine et al., 2012). These mental representations emerge from relational schemas, which are linked networks of thoughts, images, sensation, and emotions about others (Baldwin, 1992). The development of these schemas is shaped by information (and misinformation) as well as personal and vicarious experiences (e.g., Brondolo et al., 2016; Dovidio, 2009; McCoy et al., 2016; Soon, 2020). When schemas are activated, they can trigger automatic thoughts and generate implicit expectations about social interactions (Boutyline & Soter, 2021; Tett et al., 2021).

Negative stereotypes themselves are a type of schema, linking ideas about negative personal traits and the corresponding negative attitudes to images of the phenotypic characteristics associated with members of that group. The Implicit Association Test assesses implicit bias using reaction times on tasks which pair group labels and relevant stereotypes. Faster reaction times reflect the degree to which these images, ideas, and attitudes are linked together (Greenwald et al., 2022).

Social cognitive processes have measurable effects on motivation and behavior. For example, the social cognitive processes captured in measures of implicit bias have detectable effects on the quality of patient–provider communication. Higher levels of implicit bias in providers were associated with lower levels of trust on the part of their patients, and patient–provider communication was characterized by lower levels of shared information in the clinical consultation, among other negative outcomes (see Hall et al., 2015; Maina et al., 2018). Changes to implicit and explicit mental representations of others may help prevent further discrimination and mitigate its effects.

Being a target of racial discrimination also may affect social cognition. A growing body of evidence links exposure to racism to schemas, which may undermine relationships (Brondolo et al., 2012; Lewis et al., 2019). For example, discrimination has been associated with schemas embodying concerns about rejection and invalidation in personal relationships (Mikrut et al., 2021) or lower levels of trust in healthcare personnel and the healthcare system (Benkert et al., 2022).

Individual-level prejudice reduction interventions based on social cognitive theories have targeted individual-level schemas (e.g., core values) as well as social schemas (e.g., social norms). Values are schemas, embedded with emotional, visceral, and sensory responses. As schemas, values are closely linked to personal identity and capable of guiding motivation and behavior (Ferrer & Cohen, 2019). Although the results are not fully consistent (Forscher et al., 2019), values affirmation strategies which strengthen connections to core values have been associated with reductions in implicit bias and prejudice in some circumstances (Badea & Sherman, 2019).

Social norms are schemas about socially appropriate or desirable sets of attitudes and behaviors. Social norming interventions provide information about others’ behavior to motivate individuals to change their own behavior (UNICEF, 2021). These approaches have been applied with some success to reduce the expressions of prejudicial attitudes and discriminatory behavior and to increase engagement in intergroup contact (Berkowitz, 2003; Meleady, 2021; Paluck et al., 2021).

In the next sections, the paper examines cultural, institutional, and interpersonal interventions to reduce structural racism in healthcare. We examine the capacity of these interventions to engage the underlying social cognitive processes that have been identified as contributing to prejudice reduction and other positive personal or organizational outcomes. We identify moderators of the effects of social cognitive interventions to anticipate limitations to current approaches to address structural racism in health care.

Racism and Health Statements

In the first year of the COVID-19 pandemic, many institutions and organizations issued statements addressing structural racism and its impacts (Mendez et al., 2021). In the healthcare context, statements about racism and its role in health outcomes have been issued by organizations providing health services (e.g., hospitals), organizations serving healthcare professionals (e.g., the American Medical Association), organizations responsible for public health (e.g., the World Health Organization), as well as nonprofit funding and education organizations dedicated to disease, prevention, and cure (e.g., the American Cancer Society). In some cases, the statements were accompanied by an apology for past racist action (e.g., statements from the American Psychological Association and the American Nurses Association).

These statements about racism and health target social cognition. Many explicitly affirm the values of equity and inclusion and express support for egalitarian social norms, all messages which may reduce prejudice and discrimination. Many Americans believe these statements about the need to address racism have value, but others are skeptical of the motivation behind these statements and unclear about their capacity to improve racial inequalities (Anderson & Mcclain, 2020). To improve the effectiveness of these statements in reducing racism, organizations will need to take actions consistent with their stated aims (Paine et al., 2021). Guided by a social cognitive framework, we examine the content of these racism and health statements to identify ways to strengthen their impact on motivation and action.

Formal institutional statements about racism and health are a relatively recent phenomenon. Consequently, there are limited data on the public health outcomes of these statements. At present, researchers have focused on documenting the content and reach of these statements (Mendez et al., 2021) and evaluated their potential policy impacts (Paine et al., 2021).

The existing literature on the effects of organizational mission statements on organizational outcomes can provide a guide for evaluating the potential effects of racism and health statements on the expressions of structural racism in the healthcare context. In the next section, we first identify elements of organizational mission statements that are associated with key organizational outcomes and reflect elements of social cognition. Next, we identify the use of these elements in current racism and health statements.

Mission statements are generally brief statements about the purpose and goals of an organization, its values, and aspirations (Desmidt et al., 2011). Mission statements are cultural communications, directed at both external stakeholders (e.g., customers, advertisers, competitors) and internal stakeholders (e.g., employees at all levels). The presence (vs. absence) of a mission statement is not associated with improved financial performance or other outcomes. Instead, the effects on performance depend on specific components of the mission statement (Desmidt et al., 2011). Across reviews, features of mission statements which have been associated with positive performance outcomes (e.g., financial performance, organizational commitment) include a clear message of organizational goals, objectives, and values, and a focus on the stakeholders being served by the organization (see Alegre et al. (2018), Desmidt et al. (2011), and Macedo et al. (2016) for review). These components are especially important for many (Berbegal-Mirabent et al., 2021; Desmidt et al., 2011; Desmidt & Prinzie, 2009; Macedo et al., 2016; Stallworth Williams, 2008), but not all (Min et al., 2020) social or nonprofit organizations. The importance of these features is consistent with social cognitive theories about the role of values, social norms, and social relations the formation of motivation and mission commitment (Cox & Devine, 2022).

The statements on racism and health issued by many healthcare-related organizations share elements in common with mission statements. However, the statements are not intended to present the business case for the organization. Instead, these statements are more similar to the mission statements of nonprofit or social enterprise firms, in which the primary goal is to communicate a set of values and a commitment to solving a social problem for a set of stakeholders (Macedo et al., 2016).

To evaluate elements of racism and health statements, we examined statements from 12 leading organizations representing different aspects of a healthcare sector. These organizations included public health organizations (i.e., the Centers for Disease Control and the World Health Organization), professional organizations (i.e., the American Psychological Association, the American Psychiatry Association, the American Medical Association, and the American Nurses Association), health policy organizations (i.e., United States Preventive Services Task Force), healthcare delivery organizations (i.e., Health Resources and Services Administration), and the major public institution responsible for funding health-related research (e.g., the National Institutes of Health). We cannot generalize our conclusions as this is not a representative sample of organizations, nor a comprehensive review of racism and health statements from healthcare organizations. However, as can be seen in the supplemental information, the statements we evaluated illustrate a range of offerings by major organizations. We examine elements of these communications that are consistent with the social cognition components identified as linked to organizational effectiveness.

Goals and Objectives. One of the most critical components of a mission statement is a clear statement of the focus and goals of the organization. Among the statements we reviewed, most achieved this goal by defining racism and acknowledging racism as a health threat. For example, the World Health Organization (WHO) states:

Across the globe, indigenous peoples as well as people of African descent, Roma and other ethnic minorities experience stigma, racism, and racial discrimination. This situation often increases their exposure and vulnerability to risk factors and reduces their access to quality health services. The result is that these populations often experience poorer health outcomes. (WHO, 2023)

This statement (and other publicly available statements included in supplemental materials, together) illustrates the overt recognition of social determinants, including racism, as critical factors for the nation's health (Mendez et al., 2021). These explicit statements can change social norms by helping to create a consensus around the need to address racism (UNICEF, 2021).

As with mission statements in general, these racism and health statements can serve both internal and external stakeholders. Internal consumption of these statements can reinforce the goals and priorities of the organization. External communication of racism and health statements can create expectations about the experiences constituents will have when they engage with the organization.

But these goals are not meaningful without the identification of clear objectives and articulation of the strategies intended to achieve these objectives (Paine et al., 2021). Many organizations included these objectives in their racism and health statements, with different organizations prioritizing different objectives. In some cases, the objectives were outward facing, directed toward the public. For example, the American Psychiatric Association (APA)

…supports member and public education on impacts of racism and racial discrimination, advocacy for equitable mental health services for all patients, and further research into the impacts of racism and racial discrimination as an important public mental health issue. (APA, 2021)

In other cases, the objectives were more inward facing—focused on the organization's self-analysis. The American Nurses Association (ANA) explicitly aims to

develop and implement a diversity, equity and inclusion impact analysis that is considered in all policies and positions of the association. Initiate an oral history project dedicated to amplifying the contributions by nurses of color to ANA and the nursing professions. (ANA, 2022)

The objectives are clear and measurable, making it feasible to hold the organizations accountable. As commitments to antiracism evolve, public reporting of fidelity to the organizations’ objectives can prevent these statements from being purely performative (Paine et al., 2021). Organizations also may benefit from evaluating the degree to which these statements and the implementation of these objectives shift social cognition, including identification with and commitment to the organization and motivation to achieve the organizational goals (Lorenzo & Reeves, 2018).

Values. Values are key components of mission statements related to organizational performance (Alegre et al., 2018; Desmidt et al., 2011; Desmidt & Prinzie, 2009), and they have been identified as consistent drivers of individual behavior (Cox & Devine, 2022). Among the values identified in the racism and health messages were justice, inclusion, respect, and safety.

Each statement underscored the value of justice as they expressed their desire to address racism and achieve equitable treatment for all. For example, the American College of Physicians (ACP) states:

We call on our members and all internal medicine physicians to join us in this commitment so that we can work together to end racism, bias, discrimination, harassment and inequity in our society, our profession, our communities, and within ourselves. (ACP, 2020)

The WHO emphasizes its role in supporting the value of safety and inclusion for all individuals, stating:

As a global organization, WHO contributes to multilateral efforts to raise awareness of evidence-based and participatory actions to address racial discrimination and strengthen the protection of minorities, indigenous peoples and other population groups. (WHO, 2023)

Explicit statements communicating values of equity and inclusion may signal shared values to stakeholders also holding those values. Affirmations of important values may increase stakeholders’ identification with and commitment to the organization (Macedo et al., 2016). However, not all individuals share the values of inclusion and equity (Kaiser et al., 2022). Other communication strategies may be needed to reduce discriminatory actions among those who do not endorse these values (Chang et al., 2019; Cox & Devine, 2022). Organizations may benefit from a clearer understanding of how their employees’ and other stakeholders’ values are aligned with the goals described in the racism and health statements.

The literature on the outcomes of values affirmation suggests that providing individuals with opportunities to identify and endorse specific values allows them to make a personal connection to the distinct value (Sherman & Hartson, 2011). Not all racism and health statements included explicit articulation of distinct values. Identifying and defining each value in the context of the organization's functions (i.e., defining inclusion and providing examples) may help consumers imagine the operationalization of the value in practice. Offering opportunities for employees to practice articulating and affirming those values could strengthen the motivational effects of these statements.

Identification of Stakeholders. Mission statements benefit from clarity on the leadership's investment in the mission (Desmidt et al., 2011; Macedo et al., 2016; Stallworth Williams, 2008). Emphasizing the role of leadership may be essential in efforts to address racism (Hassen et al., 2021). Some racism and health statements communicate commitments from leadership. For example, the NIH statement ties their values to the President's directives, underscoring the authority behind the message:

NIH's efforts are consistent with President Joe Biden's Executive Order on Advancing Racial Equity and Support for Underserved Communities[] and is part of an overall effort by the Department of Health and Human Services to respond to the EO to improve equity, diversity, and inclusion in the federal workplace.” (NIH, 2023)

Some statements explicitly identified the stakeholders related to the organization and clarified their role in addressing structural racism. For example, the American Psychiatric Association identifies clinicians and members as key stakeholders in efforts to address structural racism stating:

[The APA…] Encourages mental health professionals to be mindful of the existence and impact of racism and racial discrimination in the lives of patients and their families, in clinical encounters, and in the development of mental health services…. (APA, 2018)

In other statements, the objective and commitment are expressed clearly, but the specific stakeholders are less explicitly identified and members of the various constituencies targeted by the statement are not identified.

Identifying the stakeholders may permit readers to develop clear mental representations of how each stakeholder associated with the organization might be affected by racism and is responsible for preventing and mitigating its effects. Each group of stakeholders may require different types of interventions: staff may need more training, community members may need more outreach, and patients may need more education and communication. Clearly specifying these stakeholders may help to engage all those whose efforts are needed to achieve health equity.

Comprehensibility. Finally, comprehensibility is one of the most critical aspects of racism and health statements (Cortés et al., 2022). The ease with which readers can decode the message is likely to influence their ability to engage emotionally with the content and may affect commitment to the message.

We examined the reading level required to read these statements using the readability statistics available in Microsoft Word, including the Flesch–Kincaid readability level. Almost all reviewed statements required reading competency above the college level. This makes it less plausible that these antiracism statements will be effective in communication with all employees or with all members of the public. Simplifying the messages, adjusting the content to a reading level easily comprehended by much of the public and all levels of the workforce, and potentially adding visual and narrative elements may maximize the positive effects of these antiracism messages.

Training to Reduce the Institutional and Interpersonal Biases

A wide range of institutional changes to address racism emerged following Title VII of the Civil Rights act of 1964 and the Equal Opportunity Act of 1972 (Anand & Winters, 2008). As a response to the legal requirement to diversify the workforce, many organizations instituted some type of diversity training for employees to help ensure compliance with the civil rights law. These training programs were largely focused on helping employees recognize and inhibit overt communications and actions that might confer risk for discrimination-related legal action (Alhejji et al., 2016; Anand & Winters, 2008; Dong, 2021). Although evidence suggests that these programs provided some sense of protection and safety for members of minority groups, they also incurred backlash and other unintended consequences (Alhejji et al., 2016; Anand & Winters, 2008).

The focus of diversity and other forms of training in culturally responsive care shifted as evidence of the consequences of racial/ethnic and other biases on health outcomes was broadly disseminated. In 2003, the Institute of Medicine report, “Unequal Treatment,” placed social cognition in the center of discussions about racial disparities in healthcare (Smedley et al., 2003). The report notes that even when healthcare providers’ behavior is not explicitly racist, implicit bias can influence the dynamic of patient–provider relationship, an essential component of effective healthcare.

By 2019, several states (including California, New York, Michigan, Maryland, and Washington) put into law the requirement that healthcare providers receive training in implicit bias and other aspects of cultural competency and bias reduction. These programs are now widely incorporated into graduate medical education and hospital training. New National Standards on Culturally and Linguistically Appropriate Services (NCLAS) were developed. These standards defined the skills required to provide culturally competent care intended to reduce health and healthcare disparities (Devine & Ash, 2022; US Department of Health and Human Services, 2002). Other institutional remedies included the use of translators and interpreters, culturally concordant patient navigators, patient education programs, and other services, which permitted health care to accommodate and be responsive to cultural variations in health knowledge and behavior (Truong et al., 2014).

Cultural competency and DEI training aim to decrease bias and improve the capacity of the healthcare system to address the needs of an increasingly diverse group of patients. This training is generally sponsored by institutions and delivered to healthcare providers with the intent of changing healthcare delivery throughout an institution or a healthcare system. Despite differences across approaches (Chae et al., 2020; Kutob et al., 2013), these programs offer components that aid providers in interpreting their patients’ symptoms and response to treatment in a broader social context. Specifically, training to deliver culturally responsive healthcare aims to enable providers to incorporate knowledge about cultural and social determinants of health, including information derived from the life history of the patient and from stories and studies of members of the social–cultural groups to which the patient belongs (Chae et al., 2020; Devine & Ash, 2022; Truong et al., 2014). When the training is effective, providers can consider the ways these life histories may change the social cognition of the patient, influencing the patient's expectations of the clinical encounter and shaping their motivations to engage in the recommended treatments.

The results of systematic reviews and meta-analyses on the effects of both DEI and cultural competency programs have yielded encouraging effects, although the outcomes are limited and not fully consistent. For instance, several reviews of DEI and antibias programs suggest that these interventions are associated with short-term improvements in attitudes and knowledge, but also underscore significant gaps in the quality of the research (Devine & Ash, 2022; Forscher et al., 2019). Some unintended negative effects have also been encountered. For example, some experimental evidence suggests White participants express concerns that organizations that provide diversity training may be biased against Whites (Kaiser et al., 2022). However, other studies provide insight into ways this type of backlash may be mitigated, including by providing an in-group ally during diversity training (Moser & Branscombe, 2023).

A review of cultural competency initiatives documented several positive improvements, including gains in provider knowledge about cultural variations in health and health behavior and attitudes toward addressing cultural variables in health care. The data also suggest improvements in the acquisition of relevant skills, such as skills in eliciting information about cultural differences in experiences, expressions or interpretation of illness and healthcare interventions (Truong et al., 2014). Several other reviews report similar positive training effects on provider knowledge, attitudes, and skills (Chae et al., 2020; Jongen et al., 2018; Oikarainen et al., 2019), although others have reported mixed effects (Rost et al., 2023). There are still very few randomized controlled trials and relatively few studies examining the patient outcomes (Devine & Ash, 2022).

Decreasing implicit bias and improving the capacity to engage with culturally diverse populations of patients are challenging tasks (Forscher et al., 2019). Reducing bias requires first identifying and acknowledging prejudice. Next, strategies must be developed to decrease prejudice and discriminatory actions towards members of other racial/ethnic groups.

But changing racial bias is not simply a matter of providing new information to modify beliefs about others. Implicit biases are social schemas (Soon, 2020; Young et al., 2003). Social schemas can be activated through multiple stimuli including seeing, hearing, or even thinking about schema-related materials. Once activated, these automatic thoughts can trigger physiological responses, including “fight or flight”-type responses (Gianaros & Wager, 2015).

Modifying schemas that are connected not only to semantic and emotional responses, but also to sensory and physiological/visceral responses may require more intensive and sustained interventions (see Devine et al., 2012; Hagiwara et al., 2020). Research on successful prejudice-reduction interventions suggests the benefit of multiple tools, including counter-stereotyping, perspective taking, individuation of others, and increasing opportunities for contact with others from diverse groups, among other methods (Carnes et al., 2015; Devine & Ash, 2022; Hagiwara et al., 2020). Each of these tools involves deliberate manipulation of social schemas, either through cognitive means (e.g., when challenging stereotypes) or through experiential means (e.g., when seeking out contact with individuals from a different racial or ethnic group).

Some data suggest that members of minority groups evaluate DEI and cultural competency training more favorably (Bezrukova et al., 2016). Individuals who live in diverse environments or who have experienced discrimination first-hand, may have developed knowledge or meta-cognitive structures about race and racism-related information. These meta-cognitive structures facilitate acquisition of new knowledge, making DEI and related training more accessible and applicable.

In contrast, individuals who have fewer experiences with discrimination or negotiating diverse environments may not have pre-existing meta-cognitive structure for processing race and racism-related information, making the training more unfamiliar and difficult and potentially reducing engagement. Some of the anticipated rejection or backlash may reflect concerns about mastering and applying detailed and unfamiliar information. Identifying allies who can support knowledge acquisition without incurring defensiveness may be critical (Moser & Branscombe, 2023)

Similarly, research suggests that the capacity of training to reduce implicit bias is moderated by the pre-existing concerns about discrimination, reflecting egalitarian values (Cox & Devine, 2022). In a study, a prejudice-reduction intervention was associated with sustained reductions in implicit bias, but only among those who expressed concerns about discrimination (Devine et al., 2012). When conducting interventions with those who do not share similar values, new approaches to implementation may be needed and additional time and support may be required to prepare individuals to absorb new information and process the complex socioemotional information which emerges in clinical encounters. The pace of healthcare delivery presents challenges to achieving these goals. Healthcare organizations will have to reconcile concerns about institutional financial goals against the imperative to achieve just, equitable, and responsive healthcare.

Interventions in Context

The success of interventions to address structural racism in health care may vary depending on the broader social context, including area and community levels of bias. Community levels of prejudice and implicit bias have been documented by studies of area-level differences in Twitter posts, Project Implicit data, and Google searches for racial slurs. These community-level variations in prejudice have been associated with a wide range of health outcomes (Michaels et al., 2022). To our knowledge, studies have not yet investigated the moderating effects of community level bias on the outcomes of DEI training initiatives on prejudice-reduction. However, higher area-level measures of prejudice influence the outcomes of individual-level psychological interventions (e.g., health behavior change interventions or psychotherapy). For Black individuals, the effects of these psychosocial interventions are substantially reduced or nonexistent if participants live in an area with high levels of anti-Black attitudes (Price et al., 2022; Reid et al., 2014).

Area-level variations in prejudice are also associated with differences in neural responses to race-related stimuli. A recent spatial meta-analysis indicated that neural activity during White individuals’ exposure to pictures of Black individuals differed depending on area-level measures of explicit prejudice taken from the Project Implicit dataset. White individuals demonstrated greater activation in two areas in the salience network (i.e., the amygdala and the dorsal anterior cingulate cortex (dACC) when they resided in areas of higher versus lower racial prejudice (Hatzenbuehler et al., 2022). One possibility is that these different patterns of neural activation influence the individuals’ subjective experience of bias, potentially modifying their response to perceived social threats or their capacity to shift perspective.

Overall, these new areas of research suggest that interventions to reduce structural racism and its effects on health may need to take contextual variables into account. The sustainability of efforts to reduce structural racism may vary depending on the racial bias individuals perceive in the context of their everyday lives and over their lifespan. Sustained and broadly disseminated efforts to communicate the value of these programs for all individuals may be needed, especially given the degree to which negative messages about diversity and inclusion have become part of political messaging (Fuchs, 2020).

The current combination of interventions across cultural, institutional, and interpersonal levels may be powerful in accelerating the rate of change in inclusion and equity in health care. Attending to the effects of these interventions on social cognition may improve these efforts. The effectiveness of statements concerning racism and health may be improved by considering the ways they activate social cognitive processes that motivate engagement in antiracist efforts. Insights from social cognition research can make the development of DEI and cultural competency programs training more efficient, reducing the burdens on individuals and the organization. Policymakers may be able to increase the pace of change by incorporating social cognition research into multilevel efforts to reduce the effects of structural racism on health and improve health outcomes for all.

Supplemental Material

sj-docx-1-bbs-10.1177_23727322231193963 - Supplemental material for Anti-Racism Efforts in Healthcare: A Selective Review From a Social Cognitive Perspective

Supplemental material, sj-docx-1-bbs-10.1177_23727322231193963 for Anti-Racism Efforts in Healthcare: A Selective Review From a Social Cognitive Perspective by Elizabeth Brondolo, Amandeep Kaur, Rebecca Seavey, Melissa Flores and in Policy Insights from the Behavioral and Brain Sciences

Footnotes

Author Note

Members of the CHIRP DEI Writing Group are (in alphabetical order): Priya Bhanot, Alexa Garcia, Julissa Osorno, Silvana Ramirez, Giavanna Varuzzi, and Kaitlyn Weydig. This paper was written as part of the training program for fellows in CHIRP—a program aimed at training young investigators to conduct research to reduce the health disparities.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Community-Driven Approaches to Address Factors Contributing to Structural Racism in Public Health (Project Director: Daniel Chen, MD) (grant number CPIMP221341-01-00).

ORCID iD

Amandeep Kaur

Supplemental Material

Supplemental material for this article is available online.

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Anti-Racism Efforts in Healthcare: A Selective Review From a Social Cognitive Perspective

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Key Points

Racism and Social Cognition

Racism and Health Statements

Training to Reduce the Institutional and Interpersonal Biases

Interventions in Context

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sj-docx-1-bbs-10.1177_23727322231193963 - Supplemental material for Anti-Racism Efforts in Healthcare: A Selective Review From a Social Cognitive Perspective

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